The common causes of acute liver failure as far as children are concerned after the viruses that are common with the adults, because these causes are there in the adults also, the more important causes after that especially so in the younger children less than 3 years of age is the causes which are inborn errors of metabolism. And these inborn errors of metabolism also involve the liver and cause liver failure. This is not usually seen in adults and this needs to be kept in mind when you are managing a patient with acute liver failure in childhood.
It is important to remember that it is very difficult even for a physician or paediatrician to be able to diagnose hepatic encephalopathy which you usually see so commonly in adults, that is not so easily seen in younger children especially infants and younger children. And sometimes becomes very difficult to diagnose. So to depend on hepatic encephalopathy for diagnose of acute liver failure is not the way to go. For acute liver failure management in children it is better to look for jaundice, it is better to look for the fact that the child is not eating well, not looking well, not playful. And then of course go forward and do the examination and the investigations which can lead to the diagnosis.
The management is more less the same, but in a few drugs which have not be found to be so beneficial in children, there is one drug called NAC that is a N-acetylcysteine there are studies very clearly mentioning that there is no benefit of NAC in non-paracetamol acute liver failure which is common on our country and then the NAC should not be used in children, especially not in under 2 years where there has been found the mortality is higher with NAC. The other thing that it is different from the rest of the management in adults is that there is definitely causes which can be easily looked after by just a change of diet and a diet restriction. Hence for doctors the difference that you find in the management of the two groups.
I think very important now is that new modalities which have come up to monitor the cerebral edema in children which is there even in adults but in children also it can be done. And it is more effective in looking after the patients with cerebral edema. Definitely it is one of the largest killers in acute liver failure and that is ultrasound based optic nerve sheath diameter which can be seen in children. The other thing is that the infections that are commonly seen in children after two weeks of them staying in the ICU are different from that of the adults and have to be look after, fungal infections are not very common in children. The third thing like I just told you is the special diets which can be used in specific management of some of the diseases.
Then of course the gene therapies are now available. These gene therapies are available for some of the causes, not for all the causes, so for that it can be look after.
Finally, like you said, disease specific management. There are these disease specific scoring systems available, like one available for Wilsons disease also which can help you in deciding the timing of liver transplant for these patients and would the patients actually need a liver transplant or what is the time for the liver transplant. Such small score actually needed for almost all diseases.